Author(s): Heather Hallman, MSHS, MHA
Quality & Patient Safety Manager - University of Colorado
Six Sigma Certified Blackbelt managing quality and safety efforts for over 10 years. I've helped to lead a case review conference for over 4 years.

Tyler Anstett, DO

Competency Domain: Patient Safety

Description: The University of Colorado Department of Medicine Systems Improvement Conference analyzes safety cases within a Just Culture lens to discover system-based issues, rather than blaming providers, for errors that occur in our hospital system. This type of analysis, called Safety I, is a reactive method to identify errors and create action items to prevent future errors. Conversely, Safety II is an analysis of exceptional care (in cases where no error occurred or a near miss) to identify best practices and proactively prevent safety errors.Problem:Case reviews are typically reactive and examine errors as they occur (e.g., when things go wrong). If we take a different approach and examine exceptional care (e.g., when things go right) also called positive deviance, we can proactively impact patient safety before errors occur.Measurement:Our case conference involves an outline of the case, a fishbone analysis of the root causes, then a discussion on potential solutions. In this case, instead of solution generation, we discussed implementing changes to recreate successes from within the case.Analysis:No statistical analysis was used.Implementation:We analyzed our case looking for the 'right' events and found several potential action items to improve safety and prevent errors. The case reviewed was an OSH transfer with a STEMI arriving on high dose pressors that unexpectedly recovered.Results/DiscussionWe found the following contributing factors to the patient's improved recovery: 1:1 nursing ratio, silo breakdown among multiple consulting teams, flattened hierarchy empowering nurse to escalate care, clear communication on level of care needed and well staffed critical care consult service.

Evaluation: Complete Poster Evaluation